Provider Demographics
NPI:1578625406
Name:EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC.
Entity Type:Organization
Organization Name:EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-783-8898
Mailing Address - Street 1:5171 GLENWOOD AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3266
Mailing Address - Country:US
Mailing Address - Phone:919-783-8898
Mailing Address - Fax:919-782-5486
Practice Address - Street 1:913 N CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3414
Practice Address - Country:US
Practice Address - Phone:704-402-1060
Practice Address - Fax:704-402-1065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9901371101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903513Medicaid
NC018KJOtherNC BCBS GROUP NUMBER
NC5903513Medicaid